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Current recommendations for the treatment of hypertension: are they still valid?
1Yale University School of Medicine, Scarsdale, New York 10583, USA. Moser@aol.com
Insights
Diuretics and beta-blockers are as effective as other hypertension medications. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are preferred for diabetic patients, often with a diuretic.
Area of Science:
- Cardiology
- Pharmacology
- Nephrology
Background:
- Current hypertension guidelines (JNC VI, WHO-ISH) require revision based on recent clinical trial data.
- New evidence clarifies indications for initial pharmacological therapy of hypertension.
Discussion:
- Diuretics and beta-blockers demonstrate comparable efficacy in reducing morbidity and mortality.
- Alpha-blockers are associated with increased cardiovascular events, particularly heart failure, compared to diuretics.
- Angiotensin-converting enzyme (ACE) inhibitors show benefits in reducing myocardial infarctions and heart failure, especially in elderly and diabetic patients.
- Calcium channel blockers have similar overall cardiovascular event rates to diuretics, but non-dihydropyridines may reduce stroke incidence.
- Angiotensin receptor blockers (ARBs) are effective in reducing proteinuria and slowing renal disease progression in type 2 diabetics.
Key Insights:
- Combination therapy, including a diuretic, is recommended for high-risk hypertensive patients.
- ACE inhibitors or ARBs, often with a diuretic, are preferred for hypertensive diabetic patients.
- Alpha-blockers should be reserved for specific conditions like prostatic hypertrophy.
Outlook:
- Future hypertension management strategies should incorporate findings from recent trials.
- Personalized treatment approaches considering patient comorbidities like diabetes and renal disease are crucial.
- Continued research is needed to refine initial pharmacological therapy recommendations.
Abstract:
Recent trials have helped to clarify indications for the initial pharmacological therapy of hypertension. Both the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and World Health Organization-international Society of Hypertension (WHO-ISH) recommendations should be revised. The more recent trials indicate that: (1) diuretics and beta-blockers appear to be as effective in reducing overall morbidity/ mortality as other agents (Swedish Trial in Old Patients with Hypertension [STOP-2], United Kingdom Prospective Diabetes Study [UKPDS], Intervention as a Goal in Hypertension Treatment [INSIGHT], Nordic diltiazem [NORDIL]); (2) the use of an a-blocker results in more cardiovascular events, especially congestive heart failure, when compared with a diuretic (Antihypertensive Therapy and Lipid Lowering Heart Attack Trial [ALLHAT]); (3)the use of an angiotensin-converting enzyme (ACE) inhibitor results in fewer myocardial infarctions and episodes of heart failure than calcium channel blockers in the elderly and in diabetic patients (Fosinopril vs. Amlodipine Cardiovascular Events Randomized Trial [FACET], Appropriate Blood Pressure Control in Diabetes [ABCD], STOP-2) - other data (Captopril Prevention Project [CAPPP]) suggest that the use of an ACE inhibitor is preferred in diabetic patients; (4) overall cardiovascular events are similar with calcium channel blockers compared with a diuretic - however, there are fewer strokes with non-dihydropyridine calcium channel blockers (NORDIL) and a trend towards an increase in heart failure and myocardial infarctions with either a dihydropyridine or non-dihydropyridine calcium channel blockers compared with a diuretic (INSIGHT, NORDIL); (5) angiotensin receptor blockers (ARBs) will decrease proteinuria and slow progression of renal disease in type 2 diabetic patients when compared with regimens that do not include an ARB or an ACE inhibitor (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan [RENAAL], Irbesartan Type II Diabetic Nephropathy Trial [IDNT], Irbesartan Type II Diabetes with Microalbuminuria [IRMA Il]). The debate over initial therapy may be moot. High-risk hypertensive patients should probably be treated initially with combination therapy, one of which should be a diuretic. The use of diuretics and beta-blockers as well as ACE-inhibitors alone or with a diuretic should be considered as initial therapy (a change from JNCVI). Alpha-blockers should be reserved for special situations, i.e. prostatic hypertrophy (in contrast to WHO-ISH recommendations). An ACE-inhibitor or ARB, usually along with a diuretic, can be considered as preferred therapy in hypertensive diabetic patients. Some data suggest equal or greater reduction in strokes with a calcium channel blocker than other medications.